Concerns of women with rheumatic disease Will I be able to get pregnant? Stay pregnant? How will my disease affect the pregnancy? How will the pregnancy affect my disease during pregnancy and post partum? In the long run? Which drugs are safe during pregnancy
Concerns of women with rheumatic disease Can a disease flare be treated safely during pregnancy? Can I breastfeed? What is the risk of passing my disease to my child?
Lessons learned from the patients Many doctors know little about the interaction of pregnancy and rheumatic disease Doctors often forget to address family planning No structured plan for interdisciplinary monitoring of disease during pregnancy Many unanswered questions about drugs during pregnancy and lactation
Risk for the SLE mother during pregnancy Flare Pregnancy complications (2-4 fold higher in SLE pregnancies) Hypertension Preeclampsia/HELLP Other complications Premature delivery and Cesarean section
Lupus activity in pregnancy Clowse M, 2007; Doria A 2002 Tow to three -fold increase in SLE activity during pregnancy. Some activity in 35–70% of SLE pregnancies The risk for a moderate to severe flare is 15–30% Risk for flare x 7.25 if SLE active before conception Most common activity: Skin Joints Hematological
SLE pregnancies carry significantly higher risks for adverse outcomes
Lupus nephritis and pregnancy Associated with increase in adverse maternal and fetal outcomes independent of histology of lupus nephritis Pregnancy-associated decline in renal function associated with severe renal impairment (Cr>250μmol/l) at conception. Conception with preserved renal function (Cr<125μmol/l) is not associated with irreversible deterioration.
Maternal complications in SLE pregnancy Bramham et al. J Rheumatol 2011, 107pregnancies
Differentiation of worsening SLE renal disease from preeclampsia: often mixed picture Clinical measurePreeclampsiaSLE nephritis hypertension++/- 24 hr. urine proteinDose not differentiate Onset of proteinuriaAbruptGradual /abrupt Urine red cell cast/active sediment RareCommon Liver function testMay be elevated in HELPnormal Abdominal painMay be elevated in HELPRare thrombocytopeniaMay be elevated in HELPMay be present ComplementNormal or highlow Anti-Ds DNANegative or stablePositive /increasing Uric acidHighNormal Urine calciumlowNormal or high Other SLE symptomsNot presentMay be present
Presence of auto-antibodies and associated risk for mother and child
Neonatal lupus syndromes Caused by transplacental passage of SS-A (anti-Ro) and SS-B (anti-La antibodies) Sjögren syndrome, SLE, MCTD, RA Transient NLS (skin, cytopenia, liver enzymes Congenital heart block
Risk of congenital heart block in SSA/SSB positive mothers In primigravidae 1-2% Higher when 1st degree AV-block is considered Sonnesson et al. Arthr Rheum 2004 Higher in Sjögren‘s syndrome than SLE 3-5 times higher risk if already one child with CHB (15- 19% CHB children) Recommendation: weekly Doppler fetal echocardiography from gestational week 16 to 26, then bi-weekly control to week 32 (Jill Buyon)
Risk assessment necessary for pre- pregnancy counseling Age Previous pregnancy complications? Irreversible organ damage present? Recent or current disease activity? Antiphospholipid antibodies / APS? Positivity of anti-Ro / anti-La? Current treatment with feto toxic drugs? Treatment with high doses of glucocorticoids Other chronic medical conditions? Smoking?
The right time and right condition for pregnancy In remission or stable low disease activity for at least 6 months Patient on stable medication with drugs compatible with pregnancy Frequency of medical controls planned Contact established between doctors involved in follow- up during pregnancy
Reasons to postpone or contradict pregnancy Patients with active disease during the last 6 months Active in any organ system Therapy with teratogenic drugs Patients with severe organ manifestations Severe renal, pulmonary, cardiac, CNS impairment or severe organ damage
Pregnancy outcome in 69 SLE subjects 69 pregnancies from 36 SLE Patients were analyzed From January 2006 till July 2012 Lupus activity index was used (SLEDI) The aim was to determine the frequency of abnormal pregnancy out comes in a cohort of SLE patient to identify the clinical,laboratory factors predicting fetal outcomes
Conclusion SLE in pregnancies in Qatar population were associated with higher risk adverse pregnancy outcomes. Disease activity during pregnancy, proteinuria, lupus nephritis and eclampsia/preeclampsia were all negatively associated with pregnancy outcome such as IUGR, still births and preterm delivery. Anti-Ro/La antibodies and low level of C3 were also associated with adverse pregnancy outcomes.
Summary and take home message Educate patients early and often Know and recommend appropriate contraception R0le out serious underlying disease related damage Timing is critical : best maternal and fetal out comes is with quiescent disease at conception Review medication before pregnancy and change to pregnancy-compatible meds. Counsel patient/partner ahead of time Close monitoring with rheumatologist,OB,and other specialty if needed.